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South Dakota rates for HCPCS J0743

Injection, cilastatin sodium; imipenem, per 250 mg

Insurance Carrier
Aetna
Facility/Professional
Facility
Modifier
Low / Median / High Price
$10.25 / $10.25 / $10.25
Aetna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.04 / $10.25 / $10.25
Cigna
Facility/Professional
Professional
Modifier
Low / Median / High Price
$7.46 / $9.33 / $9.33
Medica
Facility/Professional
Facility
Modifier
Low / Median / High Price
$7.64 / $11.78 / $19.10
Medica
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.97 / $6.97 / $10.25
Midlands
Facility/Professional
Facility
Modifier
Low / Median / High Price
$5.45 / $8.64 / $11.76
Midlands
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.42 / $8.36 / $11.76
Sanford Health Plan
Facility/Professional
Professional
Modifier
Low / Median / High Price
$11.22 / $11.22 / $11.22
United
Facility/Professional
Professional
Modifier
Low / Median / High Price
$8.71 / $10.25 / $11.28
Wellmark
Facility/Professional
Facility
Modifier
Low / Median / High Price
$6.97 / $6.97 / $6.97
Wellmark
Facility/Professional
Professional
Modifier
Low / Median / High Price
$6.97 / $6.97 / $6.97